LYNCHBURG PREJUDICE AWARENESS SUMMIT 2023 SCHOOL REGISTRATION FORM

*This form must be received by VCIC by December 9, 2022* If you have trouble filling out this form, please email Tally Botzer at tbotzer@inclusiveVA.org
Please write out the full name of the school
Select your school district from the drop down menu (click to see additional options)
Please include area code
To reach you on the day of the program (include your area code)

PLEASE SHARE THE FULL NAMES OF THE STUDENTS YOU WOULD LIKE TO REGISTER:

In order to ensure full registration and to help us create breakout groups that are as diverse as possible, all student names and completed permission forms are required prior to the program. If unable to fill in now, contact Tally Botzer (tbotzer@inclusiveVA.org) prior to December 9, 2022. If you don't plan to fill all 12 spots, type N/A.

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